Common Myths About ICAM – Busted!

ICAM – the Incident Cause Analysis Method – has been used in thousands of investigations across industries, countries, and cultures. Yet, despite its proven track record in aviation, mining, energy, healthcare, manufacturing, and government, myths still persist about what ICAM is, what it isn't, and how it works.

Let’s cut through the noise. In this article, we’ll bust the most common myths about ICAM, clarify misunderstandings, and show why it remains one of the most future-proof, flexible, and learning-focused methodologies in the world.

Myth 1: ICAM is Just Another Version of “Root Cause Analysis”

The Myth

“ICAM is just another root cause tool that focuses on finding the single cause.”

The Truth

ICAM doesn’t believe in a single “root cause.” In fact, the term itself is misleading.

ICAM is built on Reason’s Swiss Cheese Model and James Reason’s Human Error Theory, which recognise that incidents are multi-factorial and shaped by systems, organisations, and defences – not a single linear cause.

The ICAM framework explores:

• Absent or failed defences

• Individual/team actions

• Task/environmental conditions

• Organisational factors

Rather than stopping at one cause, ICAM maps interactions across layers of failure and success. It’s not about blame; it’s about understanding the system.

ICAM is not about “the” cause – it’s about “the story.”

Myth 2: ICAM Blames People

The Myth

“ICAM still focuses on human error, so it’s just a more complex way of blaming individuals.”

The Truth

ICAM is designed specifically to move beyond blame.

It recognises human error as a symptom, not a cause. ICAM seeks to understand why it made sense for a person to act as they did in that context.

Instead of asking “Who failed?”, ICAM asks:

• What conditions influenced the decision?

• What organisational pressures were at play?

• What controls or defences were missing?

ICAM supports Just Culture, acknowledging accountability while focusing on systemic learning.

Myth 3: ICAM Takes Too Long

The Myth

“ICAM is too resource-intensive for everyday incidents or near misses.”

The Truth

ICAM is scalable.

While major incidents benefit from full, team-based ICAM investigations, the principles can be applied proportionally to any event:

• A quick ICAM can be done in under an hour using the same structure.

• Many organisations use lightweight ICAM templates for near misses and quality deviations.

ICAM is a framework, not a rigid process. You tailor the depth to match the risk.

Myth 4: ICAM Is Only for Safety Incidents

The Myth

“ICAM is designed for safety – it doesn’t fit quality, environmental, reliability, or security issues.”

The Truth

ICAM’s power lies in its universality.

Its structure works wherever humans interact with systems. ICAM has been used for:

• Product quality issues (e.g., contamination, defects)

• IT failures (e.g., system outages)

• Reliability incidents (e.g., unplanned downtime)

• Environmental spills

• Security breaches

• Even business continuity and cyber events

• HR/IR events

If there’s a deviation, failure, or learning opportunity – ICAM fits.

Myth 5: ICAM Is Too Complicated for Frontline Teams

The Myth

“Only specialists or consultants can use ICAM – it’s too complex for everyday teams.”

The Truth

ICAM is designed for accessibility.

Once trained, supervisors and team leaders often lead their own investigations. Many organisations build ICAM capability at all levels – from operators to executives.

The structure of the process and tools such as the PEEPO model (People, Environment, Equipment, Procedures, Organisation) make it intuitive to follow.

No software. No additional tools. It can be done on sticky-notes, a whiteboard, or even a napkin!

Complex systems need simple thinking tools. ICAM delivers that.

Myth 6: ICAM Always Leads to the Same Answers

The Myth

“Every ICAM looks the same – just organisational factors and failed defences.”

The Truth

While ICAM provides consistent categories, the content is unique.

Every investigation uncovers a different narrative:

• Unique latent conditions

• Specific contextual pressures

• Tailored recommendations

What’s consistent is the language, not the outcomes.

That’s a strength. It allows organisations to compare trends across multiple incidents, identify recurring themes, and act systemically.

Myth 7: ICAM Doesn’t Identify Accountability

The Myth

“ICAM is too soft – it lets everyone off the hook.”

The Truth

ICAM is not a blame-free method. It’s a fair and just one.

The goal is accountability, not punishment.

It distinguishes between:

• Errors: unintended actions in context

• Violations: deliberate deviations

• Systemic gaps: organisational oversights

This allows leaders to address behaviour fairly while also fixing the system.

Myth 8: ICAM Is Only for Reactive Use

The Myth

“ICAM only applies after incidents – it’s not useful proactively.”

The Truth

Proactive ICAM is one of the most powerful risk tools available.

Leading organisations use ICAM principles to:

• Review near misses and audit findings

• Analyse high-risk tasks before incidents

• Evaluate system resilience

• Conduct learning reviews

By applying ICAM thinking before harm occurs, you prevent recurrence – and often, the first event altogether.

Myth 9: ICAM Is Inflexible

The Myth

“You must follow every step in order, or it’s invalid.”

The Truth

ICAM provides a structured roadmap, not a cage.

Investigators adapt it based on:

• Scope

• Complexity

• Available data

• Resources

The key is alignment with principles:

• Causation model

• No blame

• Systemic analysis

• Recommendations that address latent conditions

ICAM thrives in flexibility.

Myth 10: ICAM Was Created Just for Aviation

The Myth

“It’s an aviation tool – not relevant to other industries.”

The Truth

ICAM’s roots are in aviation, but its branches spread everywhere.

Developed from James Reason’s work and the Boeing Maintenance Error Decision Aid, ICAM was adapted for industrial safety and reliability by Gerry Gibb from Safety Wise.

Today, it’s applied in:

• Oil & Gas

• Mining

• Energy

• Healthcare

• Manufacturing

• Government

• Defence

• Utilities

• Transport

Anywhere humans and systems interact – ICAM fits.

Myth 11: ICAM Is Only About Finding Causes

The Myth

“ICAM’s goal is to identify causes and move on.”

The Truth

The purpose of ICAM is learning.

While identifying contributing factors is essential, the real value is in:

• Systemic recommendations

• Organizational learning

• Improving resilience

An ICAM without learning is a wasted opportunity.

Myth 12: ICAM Findings Are Only Useful to Safety Teams

The Myth

“Once the safety team files the report, it’s done.”

The Truth

ICAM findings provide insight for all functions:

• HR learns about workload and culture

• Engineering sees design and maintenance issues

• Operations identifies process weaknesses

• Leadership sees governance and priorities

• Finance sees the cost of latent conditions

ICAM outcomes fuel continuous improvement across the business.

Myth 13: ICAM Replaces Management Judgment

The Myth

“ICAM is mechanical – it removes leadership from decision-making.”

The Truth

ICAM informs decisions – it doesn’t make them.

It provides structured evidence so leaders can make better choices:

• Transparent

• Justifiable

• Traceable

It’s decision support, not decision replacement.

Myth 14: ICAM Always Ends with Recommendations

The Myth

“Every ICAM must produce recommendations.”

The Truth

Sometimes, the learning is confirmation, not change.

If defences worked as intended or the event was unpreventable within current controls, the ICAM still adds value by:

• Confirming system adequacy

• Building confidence

• Documenting resilience

Not every story needs a fix – but every story should be told.

Myth 15: ICAM Findings Always Lead to Expensive Changes

The Myth

“ICAM recommendations are too costly or impractical.”

The Truth

Effective recommendations are SMART:

• Specific

• Measurable

• Achievable

• Relevant

• Time-bound

ICAM encourages solutions at the right level:

• Procedural changes

• Training updates

• Leadership actions

• Improved supervision

• System redesign

Many are low-cost, high-impact.

Myth 16: ICAM Reports Are the End of the Process

The Myth

“Once the report is submitted, the job’s done.”

The Truth

ICAM is only valuable if actions are implemented and tracked.

The QA review, close-out process, and learning dissemination are crucial.

Without follow-through, even the best ICAM becomes a paper exercise.

Myth 17: ICAM Investigations Are Only for Experts

The Myth

“You need years of experience to conduct an ICAM.”

The Truth

ICAM is teachable.

With proper training and mentoring, anyone can learn to:

• Build a timeline

• Identify factors

• Map defences

• Write clear findings

The goal is capacity building – not dependence on specialists.

Myth 18: ICAM Is Obsolete in the AI Era

The Myth

“With AI and analytics, we don’t need ICAM anymore.”

The Truth

AI can process data – but it can’t interpret context.

ICAM captures the human story:

• Perceptions

• Judgments

• Pressures

• Trade-offs

Even with predictive analytics, understanding why people act remains essential. ICAM complements, not competes with, AI tools.

Myth 19: ICAM Is a One-Time Event

The Myth

“You do the investigation and move on.”

The Truth

ICAM is part of a continuous learning loop:

1. Event occurs

2. Investigation identifies contributing factors

3. Actions implemented

4. Follow-up ensures effectiveness

5. Trends analyzed

6. Culture evolves

ICAM isn’t a box to tick – it’s a habit to build.

Myth 20: ICAM Only Looks Backwards

The Myth

“ICAM is retrospective – it only analyses what went wrong.”

The Truth

ICAM also identifies what went right.

By analysing successful recoveries or near misses, ICAM helps organisations:

• Understand resilience

• Strengthen adaptive capacity

• Celebrate good defences

Learning from success is as important as learning from failure.

Myth 21: The Swiss Cheese Model is a Semiotic Myth with No Scientific Basis

The Myth “The Swiss Cheese Model is just a metaphor — a semiotic myth with no real science. It’s outdated and linear.”

The Truth This critique misunderstands what the Swiss Cheese Model (SCM) is — and isn’t. James Reason’s SCM was never designed as a predictive formula. It’s a conceptual framework, built from cognitive psychology, human factors, and organisational theory, to shift focus from blame to systemic learning.

It’s semiotic — yes, it uses symbols to illustrate complex ideas — but it’s grounded in scientifically validated constructs:

• Latent conditions

• Defence-in-depth

• Active failures

• Organizational factors

Empirical research in human error, HRO theory, and HFACS confirms these constructs’ relevance.

Critics are partly right: SCM simplifies complex systems, assuming linear layers and static defences. But it was never meant to model complexity — it’s a sense-making tool that communicates systems thinking simply and powerfully.

In practice, the Swiss Cheese Model:

• Revolutionised how organisations see defence failures;

• Created a shared language for investigations.

As statistician George Box said:

“All models are wrong, but some are useful.”

The SCM is useful, especially for explaining concepts to non-specialists. ICAM uses SCM as a conceptual foundation, not a constraint — turning metaphor into method through structured evidence and analysis.

Verdict 

🧀 Semiotic? Yes. 

🧠 Scientific? Yes — grounded in decades of research. 

⚙️ Useful? Extremely. 

The Swiss Cheese Model isn’t a myth — it’s a metaphor that matters.

Myth 22: Learning Teams Can Replace ICAM

The Myth

“Learning Teams make ICAM obsolete. They’re the modern, collaborative way to understand incidents- we don’t need structured investigations anymore.”

The Truth

This belief is both naïve and risky. Learning Teams are not an investigation method- they are a discussion format. They rely on group conversation and subjective recollection, without the discipline of evidence collection, causal analysis, or systemic traceability.

While the concept of “learning” sounds appealing, unstructured discussions cannot replace a methodical investigation when incidents involve harm, high risk, or organisational accountability. Without ICAM’s structure, Learning Teams often:

• Drift into speculation and storytelling, rather than analysis.

• Fail to distinguish between contributing factors and opinions.

• Produce inconsistent findings that can’t withstand legal or governance scrutiny.

• Generate unverifiable conclusions based on perception, not data.

ICAM exists to impose discipline, evidence, and defensibility on the learning process. It demands:

• Verified timelines and data correlation.

• Analysis of latent conditions and defence failures.

• Logical cause-and-effect reasoning.

• Recommendations that address systemic vulnerabilities.

Learning Teams, on the other hand, typically end when the conversation does. ICAM continues until the systemic truth is established and corrective action is verified.

Why the Confusion Exists

Learning Teams are marketed as a way to make safety “more human” and “less bureaucratic.” But this often reflects a discomfort with rigour, not a genuine methodological improvement. Removing structure doesn’t make learning deeper — it makes it shallower and subjective.

The Verdict

• 🧠 ICAM is a formal, defensible, evidence-based investigation framework.

• 💬 Learning Teams are informal conversations, useful for engagement but not a substitute for analysis.

• ⚖️ When accountability, reliability, and accuracy matter, ICAM remains essential.

Learning Teams might talk about what happened- ICAM proves why it happened. In complex organisations, only one of those can stand up to scrutiny.

Why These Myths Persist

Myths often arise from:

• Poorly trained investigators

• Rushed investigations

• Misuse of the tool

• Management misunderstanding

• Deviations from the process

• Lack of follow-up

When ICAM is implemented correctly, with leadership support and trained teams, these myths vanish.

The Future of ICAM

As organisations face complex, high-velocity risks, ICAM’s systems-thinking foundation becomes more valuable than ever.

Modern ICAM practice includes:

• Digital data capture apps

• Virtual investigations

• Cross-functional learning teams

• Integration with risk and governance frameworks

• Proactive use for predictive learning

ICAM evolves because learning never stops.

Key Takeaways

• ICAM is not a root cause tool – it’s a systems learning framework.

• It’s scalable, flexible, and applicable across all domains.

• It’s not about blame, but about learning.

• The myths fade when ICAM is used with integrity, training, and leadership support.

• The goal isn’t to fill boxes – it’s to build better systems.

Final Word

The most dangerous myth is thinking you already know why something happened.

ICAM exists to challenge assumptions, uncover hidden conditions, and build safer, stronger, smarter organisations.

When used properly, ICAM turns incidents into insights – and failures into fuel for progress.